other causes of fever

T e c h n i c a l S e m i n a r s

Other Causes of FeverFebrile Illness

Causes

Fever After Seven DaysReferral

Relapsing Fever - BorreliosisOverview • JHR • Adaptation

Sore ThroatOverview • Prevention • Management

Treatment • Adaptation

Dengue FeverOverview • Referral

Treatment Plan and Adaptation

O t h e r C a u s e s o f F e v e rO t h e r C a u s e s o f F e v e r

• Fever as a secondary cause– management of the condition results in

management of the fever– pneumonia, measles, dysentery, ear infections,

runny nose

• Fever associated with severe illnesses which use danger signs for classification and treatment– meningitis, septicemia sepsis

Febrile IllnessCauses


• Fever associated with malaria, the main focus of IMCI Guidelines – difficult to distinguish malaria from other

common causes of infection without extensive clinical examination and laboratory testing

– malaria covered in a separate seminar



• Non-localizing signs do not allow for distinction at a first-level health facility

• Danger signs identify a seriously ill child who needs to be referred– Peritonsillar abscess

– Typhoid

– Relapsing Fever

– Dengue



• Differentiates between simple viral fevers and other diseases where the only presenting symptom is fever

• Detects conditions needing diagnostic and therapeutic intervention– Tuberculosis, HIV/AIDS, urinary tract

infection, relapsing fever, typhoid, osteomyelitis

Fever after Seven DaysReferral


• Conditions do not have any obvious simple clinical sign but have fever in common

• Prevalence too low to include specific signs and symptoms for each condition

Fever after Seven DaysReferral


• Recurrent attacks of fever lasting three to five days that relapse and remit

• Caused by a spirochete of the Borreliaspecies and transmitted by lice and soft body ticks

• Symptoms– chills, severe muscle pain, headache, joint pain, petechiae,

stiff neck, jaundice, hepatosplenomegaly, abdominal tenderness

• All signs less clear in children under 5 years

• Mortality 70% if untreated; 5% or less if

Relapsing Fever - BorreliosisOverview


• Treatment for relapsing fever is relatively simple

• Most mortality in treated patients due to the JHR– occurs within the first one or two hours after the first

antibiotic dose

– caused by the release of TNF and cytokines caused by lysisof the spirochete

– characterized by high fever chills and aggravation of existing symptoms, tachypnea, vasoconstriction, high blood pressure, shock

• Observe patients for several hours after i i h fi d f ibi i

Relapsing Fever - BorreliosisJarisch-Herxheimer Reaction (JHR)


• Tetracycline effective, but associated with 45 percent rate of JHR and case fatality rate of 5 percent

• Low dose procaine penicillin results in a 5 percent JHR rate with no case fatality, but a high rate of relapsesRegime % JHR % RelapsesC.F.R.%Tetracycline 45 0 5Low dose P.P. 5 >45 0High dose P.P. 30 Low 5



• Antimicrobial treatment alone is not sufficient– delouse, boil personal clothes, burn blankets,

shave head, and spray dwelling



• High risk malaria - suspect relapsing fever in all children with persistent fever or remission/relapse pattern.

• Low or no risk malaria - treat on suspicion in known relapsing fever situation as ”other cause of fever" or in follow up.

Relapsing Fever - BorreliosisAdaptation


• Suspect relapsing fever if other cases are occurring and the child has high fever with chills and headache. Treat with procaine penicillin.

• Adapt guidelines to include counselling mother on personal hygiene and delousing.

• Add procaine penicillin box to guidelines.

Relapsing Fever - BorreliosisAdaptation


• Streptococcal sore throat and rheumatic fever predominately in children older than 5 years

• IMCI Guidelines don’t address the child over 5 years

• Main reason to treat streptococcal sore throat is prevention of rheumatic fever and rheumatic heart disease

• Rheumatic heart disease accounts for 1.1 percent of deaths in developing countries– Ghana study in 1981 - 1% of healthy days of life lost due to

RHD

Sore ThroatOverview


• WHO recommends secondary prevention of rheumatic heart disease– Does not prevent RHF but prevents its progression

– Prophylactic benzathine penicillin every 3 to 4 weeks to children who have had rheumatic fever

• Ideal prevention of rheumatic fever entails treatment with streptococcal pharyngitiswith penicillin– Limited use in developing countries because of expense

– Directed at school-age children and of little use to children under 5

Sore ThroatPrevention


• Management of sore throat is complicated by many factors

– 30-50% of RHF follows unapparent infection

– 15-20% sore throats are Group A Streptococcus and reliable signs are needed to avoid over-treatment

– Selection of signs to use remains problematic

– Children under 3 often have non-specific signs such as fever and crusts around nose

– GAS infections generally rare in children under 2 years

Sore ThroatManagement issues


• Sensitivity and specificity tend to move in opposite directions

• Difficult clinical diagnosis of GAS infection without rapid diagnostic test or routine cultureClinical feature Sensitivity % Specificity %History of fever 92.314.4Temp >38ºC 37.4 66.0Exudate 31.031.0Enlarged node 81.3 45.1



• High prevalence RHF or RHD - high sensitivity is better

• Low prevalence - high specificity is better to prevent over-treatment



• Treatment to prevent RHF and RHD, but also reduces duration of symptoms and signs, and anorexia

• Single dose of IM Benzathine penicillin remains best treatment– levels of penicillin remain elevated for up to 10 days– can prevent a sore throat developing for up to 21 days later– administration can be very painful and incorrect

administration can cause sterile abscesses, sciatic nerve injury

• Penicillin V or amoxicillin are alternatives but more expensive and 10-day compliance is poor

Sore ThroatTreatment options


• Sore throat is common, but not a major cause of mortality

• Treatment (injection of benzathinepenicillin) is expensive

• Lack of reliable clinical signs leads to over-treatment of sore throats

Sore ThroatAdaptation


• Possible adaptation depends on:– prevalence of GAS sore throat

– sensitivity and specificity of the signs and symptoms being considered

• Option to use the ARI box ‘as is’ and accept low sensitivity but should not be used on younger children

Sore ThroatAdaptation


• Problem in Asia and becoming a significant problem in Latin America and east Africa

• Presents as shock or bleeding, occurs in epidemics every 3 to 4 years

• Major and politically important cause of morbidity in some countries

• Most common in children 5-15 years but not less than 5 years

• Untreated, mortality can be up to 10 percent, but when treated effectively, as low as .5 percent

Dengue FeverOverview


• First-level treatment comprises management of shock and referral

• Major clinical manifestations– Shock -- circulatory failure– Hemorrhage– Fever (with or without hepatomegaly that is tender)

• Selection of signs for the algorithm depends on– Predictive value– Feasibility– Types of treatment available

Dengue FeverOverview


• Signs and symptoms needing referral– Shock

– Cold clammy extremities, severe bleeding from nose or gums, black vomit or stools (3)

– Weak or undetectable radial pulse, skin petechiae, frequent vomiting, abdominal pain (2)

– Capillary refill time >3 seconds, lethargy or restlessness, right upper abdominal tenderness, positive tourniquet test, petechiae plus positive tourniquet test (1)

• Algorithms from Indonesia, Philippines and Vietnam show great variation in type and number of signs used

Dengue FeverReferral


• Signs requiring observation– Abdominal pain (1)– Restless (1)– Skin petechiae + negative tourniquet test (1)– High continuous fever for 3 days or more (1)– No other apparent cause of fever (1)

• Studies show only shock and mucocutaneousbleeding had specificities and sensitivities over 80 percent

• Other signs and symptoms add considerably to the complexity of the algorithms

Dengue FeverReferral


• Main treatment plans that fit needs of most national guidelines– Management of shock - Plan C or modified

– Management of potential fluid loss - Plan A

– Observation - watch for any sign of bleeding or worsening

• Adaptations problematic because of inadequate analysis of data to define best signs and symptoms

Dengue FeverTreatment Plan and Adaptation

other causes of fever

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